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09/19/2001 09:46 7073745677, WOODWARD DRILL.ING-GD AG. <br /> Qfli l5/M901 11:48 2fi9-578 i MU ESTO ATC I <br /> San.loaquin County cnvironmanta! Nealtft 5ervlcrs, Unit IV Wall fserM.I4 AppIjcgden Supplement <br /> ! <br /> JOB ADDRE534//s -Vit. PERMIT SR#.-D02--f? <br /> I <br /> LICENSED GC.`NT'RACTOFI $ DECLARATION LrD) <br /> I hereby affirm that I am licensed under the provisiors.of Chapter 9 (cominiRnc(ng watt Sei-tion 7ODtt}Qf vi%dsicn <br /> 3 of the Susinera -and Professions Code end my license is in fuli force and effect <br /> License Ai:. -.( l_A 1_ ._ _ »� Exp@atlom D,ta�tC:: ._�(�w��8 <br /> Oate: ! _pU{ Contmrtor: <br /> Slorlature: _.W ._._. Trifle: 4f�6Th" s?S tD1.4w?er} t <br /> Printadname: <br /> WORKERS' COMPENSATION DECLARAMN � <br /> j affirm under penalty of perjury One of the following deGHrat101)3: fC XC:t4 ALL THAT APPLY) <br /> n.ie and will maintain a cartirtoate of consent to saif•insi.tre for workers'aempensation, si.;pro+Ked for by <br /> section 3700 of the Labor Code, for the performance of the work far Ahidt ails permit is isnu. <br /> I heave and wif' makitain workers'cnmKx nsation insurance, as required t>y Seet',ott 3700 of the tabu Code, <br /> for lime petrtermartce of Vie work for which thlS pemtit 15 Issued. My workk r5' txmpensrtian insurance � <br /> carrier and pte',1cy humbers are: I . <br /> 1 Carrier: ,. 71A f la O Poiicy Ntambon _....__Q5?.. ._ f <br /> I certify,thsi in tho. pvt'orman,no of the work for which this panr4l ig ie&ue�, t Shall nel a nett y eny person in <br /> " gory mannetr so at;to best',ome subject to the workaW Oompensaticn lawn of C;a cril'sa, *rid agree trial if I <br /> should become subject to the workers' compensation provAslons of Secticrit 3700 Of th6 Labor Code, t stleri <br /> torthwdh comply with tho*e provisions. {i <br /> Date: _Signature; <br /> Printed Name:_._(, ' <br /> WARNING: FAILURE TO SPCURIA2 4h' RXF—RS'COMPENtakri 7N COVVRAGE IS UNLAWFUL,Ami SMALL SU&IEC, <br /> AN EMYLO`rf9RT0 CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDREd THOUSAND DOLLARS ' <br /> - (S100,000.), 04 A.DDtTiON TO THE COST OF COMPENSA'noo,It4TER2ST,A.TTORNEyS FE28, ANJ DAMAGES AS ' <br /> PROADI:.D FOR IN SECTION 3106 OF THE LABOR CODE. <br /> Ilconsed authorUIsd reprr6aent f.»),hereby <br /> ; to-sign this Son .feoquin County Well Permit Appliratlm on my behalf. f undomiand thte authorixatior,Is valid for <br /> } ane(1)ye,yr and Is limited to the were Pisa dated on too frpnt page.or two appiiemde,n. <br /> tlllll <br /> 3-17-20041 Mf <br />